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Put this on your checklist

A must-read for everybody—from surgeons to housekeeping staff—involved in patient care, feels Dr Naresh Trehan.

Dr Naresh Trehan | Print Edition: July 11, 2010

This book should be mandatory reading for all those involved in the care of patients. Surgeons, by their very training, are taught to be obsessive, but the complexities of modern medicine mean that it is not the "captain" of the ship alone who is responsible.

Large teams of doctors, technicians, radiologists, as well as services such as housekeeping and purchase, have to be equally involved to produce the best outcome for patients. Gawande's unputdownable book is littered with real-life stories from hospitals, airlines, the building industry and even chefs.

Making checklists and breaking down procedures into steps have increased efficiency and lowered accidents. Gawande quotes several examples such as the work of Dr Peter Provonost, a critical care specialist, in reducing ICU infections and how Steven Luby handled seemingly difficult tasks such as reducing incidents of diarrhoea and respiratory infections in a third-world slum.

As Gawande says: "We, as surgeons, want to believe that our teamwork is exemplary, but studies show this to be far from the truth. In one survey of more than 300 people coming out of the OT, one out of eight was not even sure where the incision would be until the operation started!"

The number of surgeries has grown tremendously even as the procedures themselves have become more complex. Things that were not possible 25 years ago are routine today and people often joke about surgeons for "the right ear and for the left ear!"

So, it is not surprising that iatrogenic (illness caused by medical treatment) death now accounts for 98,000 patients annually. In a country as developed as the United States, this equals to two jumbo jets colliding over the skies every day! Then, different countries have different levels of resources, both human and technological.

To help tackle this problem, the World Health Organisation has developed a simple surgical checklist, which, if implemented, would succeed in reducing such errors by over 30 per cent. This work was done in six different countries with different cultural and financial backgrounds, as far apart as Boston and Tanzania.

More and more hospitals and organisations have recognised the value of procedures and protocols not only in tackling problems, but in preventing them from happening. In a medical world where just trauma means different injury-related diagnosis and 3,261 unique combinations, the protocol needs to be simple, easy to understand for everybody in patient care, and across regions.

We have spent billions of dollars on the development of modern medicine technology but, as Gawande points out, there is no institution devoted to health safety. Medicine and research have become so specialised and so demanding that in spite of efforts, there are bound to be accidents. The challenge is to bring those rates down to the bare minimum.

Death and morbidity are going to be a part of surgical treatment given that patients with more complicated problems require treatment, sometimes at the extremes of what is clinically possible.

I would commend Gawande for bringing out this book, highlighting in a very readable manner the aim of procedures and protocols. He has given examples from different industries as to how they have improved their outcomes and how it is possible to translate these numbers into good surgical practice.

The reviewer, a renowned heart surgeon, is Chairman and MD of Medanta-The Medicity

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